Qualitative evaluation of the chance to the UK human inhabitants of monkeypox an infection in a canine, feline, mustelid, lagomorph or rodent UK pet

Concerning the Human Animal Infections and Danger Surveillance group

This doc was ready by the UK Well being Safety Company (UKHSA) on behalf of the joint Human Animal Infections and Danger Surveillance (HAIRS) group.

HAIRS is a multi-agency cross-government horizon scanning and danger evaluation group, which acts as a discussion board to determine and focus on infections with potential for interspecies switch (notably zoonotic infections).

Members embrace representatives from the UKHSA, Division for the Atmosphere, Meals and Rural Affairs (Defra), Division of Well being and Social Care (DHSC), Animal and Plant Well being Company, Meals Requirements Company, Public Well being Wales, Welsh Authorities, Public Well being Scotland, Scottish Authorities, Public Well being Company of Northern Eire and the Division of Agriculture, Atmosphere and Rural Affairs for Northern Eire.

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Info on the chance evaluation processes utilized by the HAIRS group might be discovered at HAIRS risk assessment process.

Model management

Date of this evaluation: 22 Might 2022

Model: 1.0

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Cause for the evaluation: Stories of human-to-human transmission of monkeypox virus within the UK; issues for pets within the houses of contaminated individuals.

Accomplished by: HAIRS members.

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Non-HAIRS group consultants consulted: Dr. Lorraine McElhinney, Dr. Pip Beard.

Date of preliminary danger evaluation: N/A

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Info on the risk assessment processes used by the HAIRS group might be discovered on-line.

Abstract

In Might 2022, human-to-human transmission of monkeypox virus was noticed in a number of non-endemic international locations, together with the UK.

Throughout a earlier monkeypox incident within the UK in 2018, a pet administration course of needed to be swiftly applied for one affected family, with out conducting a danger evaluation a priori.

Because the numbers of affected households within the UK associated to the present outbreak are quickly rising, this warrants a extra thorough evaluation of the chance posed by mammalian pets uncovered to monkeypox virus to individuals with whom they might come into contact.

For the needs of the evaluation, it’s presumed the pet is current within the contaminated family of a confirmed human monkeypox case. The chance posed is subsequently to the non-infected human contacts or in-contact peridomestic or wild rodents. It’s concluded that the best danger is posed by the presence of pet rodents, extra so than lagomorphs, canids, felids and mustelids.

It’s unlikely (however can’t be dominated out) that an contaminated rodent pet may unfold an infection to peridomestic or wild rodents. As rodents might not present medical indicators of an infection, and the incubation interval is unknown, testing to detect the presence of antibodies in addition to virus would offer extra confidence in ruling out an infection.

The proof of susceptibility for non-rodent pets is poor or incomplete, and subsequently a precautionary danger administration course of needs to be thought of.

Primarily based on present proof, for pet rodents in households the place there are contaminated individuals, momentary elimination from the family for a restricted quarantine interval (21 days) and testing to exclude an infection is really helpful, notably the place there are contaminated human contacts who’ve had shut direct and extended contact with the animal or its bedding and/or litter.

Acceptable danger administration for laboratory employees dealing with samples, or vets and animal well being professionals dealing with or taking samples from the pets, must also be established.

Evaluation of the chance of an infection to the human inhabitants within the UK

Likelihood: common inhabitants – very low.

The likelihood of an infection can be thought of average to excessive for people interacting with contaminated pets (notably rodents) and their contaminated environments.

Affect: very low to low.

Degree of confidence in evaluation of danger

Passable.

Proof is incomplete for the susceptibility of endemic UK rodent populations to monkeypox an infection, however there’s proof for non-native rodent susceptibility; restricted or no proof for susceptibility of non-rodent mammalian pets. Some proof from earlier outbreaks of animal-to-animal transmission or rodent-to-human transmission.

Motion(s) and/or suggestions

Take away rodent pets from a family to safe lodging, isolate for Class 3 pathogen, keep for 21 days and take a look at adverse (PCR) for launch.

Keep different mammalian pets beneath family isolation with common vet checks to make sure no medical indicators are noticed.

This danger assessments addresses:

  • the general chance that an animal will turn into contaminated with monkeypox virus by shut direct and extended contact in a family with an contaminated human, and that this might result in additional human infections
  • the belief that the naïve animal has already had contact with a identified human confirmed case and subsequently grew to become contaminated would depend upon the species of animal and the medical severity of the human case or degree of contamination within the setting
  • the chance pathway for additional transmission to people, which isn’t solely direct contact between a naïve human and the contaminated pet, however the potential for the contaminated pet to transmit to endemic wild, peridomestic or home animals, by direct contact or contact with a contaminated setting, after which to people
  • this danger evaluation doesn’t deal with human-to-human transmission of monkeypox virus

Step 1. Evaluation of the likelihood of an infection within the UK human inhabitants

This part of the evaluation examines the chance of an infectious risk inflicting an infection within the UK human inhabitants. The place a brand new agent is recognized there could also be inadequate info to hold out a danger evaluation and this needs to be clearly documented. Please learn together with the Likelihood Algorithm discovered at Annex A.

On this circumstance, we’re assuming monkeypox virus an infection is already current in an individual proudly owning a pet within the UK, and that the pet might turn into contaminated, giving rise to extra human instances.

Transmission is prone to be through shut contact with the contaminated animal (bites, scratches, respiratory droplets) or contaminated fomites within the family setting. We’re contemplating the susceptibility of the pet species concerned, and never the chance of the pet changing into contaminated from the contaminated human and/or contaminated setting.

Is that this a recognised human illness?

End result: sure.

High quality of proof: good – people; passable – rodents; poor – different species.

Monkeypox (MPX) is a uncommon zoonosis that may trigger human sickness clinically indistinguishable from smallpox (1). It’s brought on by the monkeypox virus (MPXV), which is an orthopoxvirus that’s genetically distinct from different members of the Poxviridae household, together with the variola, vaccinia, ectromelia, camelpox, and cowpox viruses. It was first recognized as the reason for a pox-like sickness in captive monkeys on the State Serum Institute in Copenhagen in 1958 (2).

MPX is considered crucial orthopoxvirus an infection in human beings for the reason that eradication of smallpox (3) Against this with variola virus, nonetheless, MPXV has a variety of hosts (4), which has allowed it to keep up a reservoir in wild animals whereas sporadically inflicting human illness (13). It subsequently can’t be eradicated by human vaccination alone, though it could be attainable to be managed by focused vaccination of people (utilizing a smallpox vaccine, which is accepted to be used towards MPX) and culling animal reservoirs in sure circumstances.

The primary human case of MPX was recorded in 1970 within the Democratic Republic of the Congo (DRC) (5), and since then the an infection has been reported in a lot of central and western African international locations, the place it’s thought of endemic. Most human instances are reported from the DRC and Nigeria, with clusters of MPX instances often being reported in Central African Republic (CAR).

Sporadic instances have been reported in Cameroon, Gabon, Côte d’Ivoire, Liberia, the Republic of the Congo, Sierra Leone, and South Sudan (6 to 11).

In 2022, outbreaks of MPX have been reported in Cameroon, CAR, the DRC and Nigeria (12), though the true variety of instances could also be under-reported given restricted surveillance and diagnostic capacities in these international locations.

There are 2 clades of MPXV, a West African clade (traditionally present in Sierra Leone, Nigeria, Liberia, Ivory Coast, and Gambia), and the Congo Basin clade (or Central African clade) discovered predominantly within the DRC and CAR.

The case fatality fee (CFR) can differ between 1% and 10%, however it’s clade dependent with the West African clade inflicting decrease mortality (13) To this point, Cameroon is the one nation the place each clades have been detected (13).

In 2003, a big outbreak of human instances of MPX was detected within the USA, which was related to the importation of pet rodents from West Africa. Laboratory testing by the US Facilities for Illness Management (CDC) and Prevention confirmed that 2 African large pouched rats, 9 dormice and three rope squirrels had been contaminated with MPXV.

After importation into the USA, a few of the contaminated animals had been housed close to prairie canine on the services of an Illinois animal vendor. These prairie canine had been offered as pets earlier than they developed indicators of an infection. Consequently, there have been 47 confirmed and possible human instances (no deaths), and no human-to-human transmission was reported (14).

Is the illness endemic within the UK?

End result: no.

High quality of proof: good.

MPX will not be an endemic illness within the UK. Previous to 2022, 7 instances of MPX had been reported (all West African clade) within the UK, all of which had been, or had been linked to, journey related instances. In 2018, 2 instances of MPX had been recognized within the UK in people who had travelled from Nigeria (15). The instances had been epidemiologically unconnected.

A 3rd case was recognized with MPX in 2018, following contact with contaminated mattress linen. The case was a healthcare employee concerned within the care of one of many earlier instances (16). In 2019, a person in England was confirmed to have MPX after lately travelling from Nigeria.

In Might 2021, a case of MPX was recognized in Wales, additionally with a journey historical past from Nigeria. On this incident, 2 members of the family had been subsequently recognized as having MPX and all 3 instances recovered (17).

On 7 Might 2022, the UK Well being Safety Company (UKHSA) introduced a confirmed case of MPX in a person with a journey historical past to Nigeria (18). The case developed a rash on 29 April and arrived within the UK on 4 Might, having departed Nigeria on 3 Might. Intensive contact tracing was undertaken to determine and follow-up uncovered contacts of the case in healthcare settings, the neighborhood and the worldwide flight.

On 14 Might, 2 MPX instances had been recognized in London who weren’t linked to the case reported on the 7 Might (18).

4 new instances had been recognized on the 16 Might; 3 in London and 1 case within the North East of England (18). None of those instances have identified hyperlinks to these reported on the 7 and 14 Might and there was no hyperlink to journey to a rustic the place MPX is endemic.

Precisely the place and the way they acquired their infections stays beneath pressing investigation, together with whether or not they have additional epidemiological hyperlinks to one another. Genomic sequencing confirmed the instances had been contaminated with the West African clade of the virus (18).

As of 21 Might 2022, a complete of 91 confirmed instances had been reported throughout 13 international locations together with Spain (30 instances), Portugal (23 instances), the UK (20 instances), Canada (5 instances), Italy and Belgium (3 instances every), Australia (2 instances), and one case every in France, Germany, Netherlands, Sweden and the USA (19).

Are there routes of introduction into the UK?

End result: sure.

High quality of proof: passable.

The chance of latest introductions of MPX to the UK will depend on the extent of the circulation of the virus in different international locations. Previously, people with a journey historical past to Nigeria and the DRC had been thought of as these of highest danger of importation of MPX.

Given the geographical growth of non-endemic international locations now reporting confirmed instances of MPX (see above) and neighborhood transmission in a few of these international locations – the extent of which is beneath investigation – then new journey related instances within the UK can’t be excluded.

The chance to the UK public would come from a human case of MPX being imported into the UK, which depends on the variety of travellers anticipated from affected international locations and direct, fast journey routes, or the import of an contaminated animal reservoir.

The latest instances usually are not the primary to be reported within the UK, however are uncommon with respect to the broader human-to-human transmission.

The motion of primates or rodents for industrial causes or as pets into Nice Britain is regulated by the Rabies Import Order (The Rabies (Importation of Canines, Cats and Different Mammals) Order 1974), and the Rabies (Importation of Canines, Cats and Different Mammals) Order (Northern Eire) 1977, which might require all animals to endure 6 months quarantine in a rabies-approved quarantine kennel after entry, except ready for pet journey or a derogation is utilized (corresponding to for accepted institutions like zoos).

Industrial actions from Europe and their massive unique pet markets could also be undertaken beneath licence and don’t require a well being certificates. Quarantine institution kennels usually are not essentially rodent proof, however are designed to forestall the escape or deliberate launch of animals and to handle transmission of rabies between these animals current.

Are efficient management measures in place to mitigate towards these routes of introduction?

End result: sure – people; no – rodents and non-rodent mammalian animals.

High quality of proof: passable.

Human-to-human transmission might happen by contact with clothes or linens (corresponding to bedding or towels) utilized by an contaminated particular person, direct contact with MPX pores and skin lesions or scabs, or by respiratory droplets when an contaminated particular person with a MPX rash coughs or sneezes (13).

Thus, stopping direct contact is probably the most applicable management measure. Human instances might be handled and ring vaccination (utilizing smallpox vaccine) of contacts might be utilized. After an infection, and as soon as the scabs have dried up, the affected person is not infectious and there’s a robust immune response.

Efficient decontamination of the setting frequented by an individual with MPX can be needed (20). While the virus (enveloped DNA virus) is extremely resistant within the setting to temperature, it may be destroyed with detergents.

If an infection is current in small mammals that are imported as a part of the unique pet commerce from the European Union (EU), there aren’t any efficient management measures to forestall imports. No border checks are in place for the motion of such animals and there’s no well being certificates required. Industrial paperwork usually are not routinely examined for such imports.

There aren’t any harmonised well being certificates for the industrial import of rodents into the EU from third international locations, and MPX will not be notifiable beneath the EU Animal Well being Legislation Fee Implementing Regulation EU/2018/1882.

As soon as imported into the EU, they might not be topic to quarantine on arrival within the UK, except they’re declared as originating in a 3rd nation, as a result of derogations are routinely given for EU-origin animals. Unique pet commerce gala’s are commonplace within the EU.

Subsequently, vulnerable mammalian pets that had been in direct shut contact with an contaminated human needs to be remoted for a interval equal to the human most incubation interval of 21 days. Veterinary administration of animal sufferers includes symptomatic therapy and supportive care, as required.

Do environmental circumstances within the UK help the pure reservoirs or vectors of illness?

End result: sure.

High quality of proof: passable.

Numerous animal species have been recognized as vulnerable to MPXV. Rodents are thought of pure reservoirs of an infection, together with rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates (21) and different species (22).

Uncertainty stays in regards to the pure historical past of MPXV and additional research are wanted to determine the precise reservoir(s) and the way virus circulation is maintained in nature. Nonetheless, there’s laboratory proof of susceptibility for the pink squirrel, Sciurus vulgaris (22) and for sure wild derived strains of Mus musculus, the home mouse.

Though there is no such thing as a proof of susceptibility of frequent endemic wildlife species within the UK to MPXV, rodents (together with voles, dormice, rats, mice, and squirrels) in addition to lagomorphs (rabbits and hares) and hedgehogs may all be thought of potential reservoirs, primarily based on subject and laboratory observations (22).

Investigating small rodents corresponding to rabbits, floor squirrels, prairie canine, cotton fee, white rats, golden hamsters and guinea pigs as animal fashions for MPXV demonstrated various ranges of susceptibility relying on route of inoculation and age of the animal (23).

Lack of medical indicators in contaminated grownup white rats and white rabbits helps the speculation that the medical final result will depend upon the route of inoculation or age and immune standing of the animals (23). This, coupled with potential for viral shedding and restricted knowledge on pathogenesis, offers low confidence in diagnostic predictive values utilizing completely different sampling matrices or within the incubation interval.

In 1979, a large-scale survey of animals (representing at the very least 43 species) within the DRC detected proof of constructive serology for Orthopoxviruses amongst non-human primates, in addition to proof of at the very least one species of terrestrial rodent, primarily squirrels, exhibiting presumed MPXV-specific reactivity (24). This was in keeping with findings that ~12% of individuals presumed to have been contaminated by contact with animals had current contact with squirrels (25).

Not one of the home animals examined – 120 sheep and goats, 67 cats – exhibited serologic proof of Orthopoxvirus an infection [(26)(#references). In 1985, the isolation of MPXV from a captured, symptomatic squirrel (Funiscirurs anerythrus) was made (24).

The only other instance of virus isolation from a wild animal was in 2012 from a juvenile sooty mangaby (Cercocebus atys) from Côte d’Ivoire (27).

The range of taxa capable of supporting infection with MPXV is wide, though several common peridomestic rodents have been ruled out. Adult white rabbits and white rats (genus Rattus) have been observed to be refractory to infection with MPXV, but not newborns (reviewed in (5)).

Nearly all sub-species of the common house mouse, Mus musculus, are resistant to challenge with MPXV when adult animals with functional immune systems are used (28).

One exception to this is the castaneous (CAST) subspecies of the house mouse, Mus musculus castaneus, due to intrinsic low levels of IFN-γ and TNF-α responses and overall fewer NK cells and CD4+ and CD8+ T cells (29).

Outbreaks among captive animals on display or kept as pets reveal further evidence for the involvement of animals: 2 New World giant anteaters (Myrmecophaga tridactyla) were infected with MPX at the Rotterdam zoo outbreak in 1964, during which individuals from 7 different species of non-human primates became ill and in some cases died (30).

While anteaters are not considered to play a role in the natural lifecycle of MPXV, it is possible that transmission hosts need not be natural, maintenance hosts of the virus. Captive animals seem particularly vulnerable to the epizootic spread of MPXV, whether due to crowding, species mixing, or physiological stress, a fact underscored by 2 outbreaks at primate sanctuaries in Cameroon (31).

Under experimental conditions, susceptibility of rabbits to MPXV has been shown (32) and infection of an African hedgehog was confirmed in the 2003 USA outbreak (33). The susceptibility of wild or pet/captive Mustelidae to MPXV is unknown.

In 2003, in the USA, MPXV was introduced to several mid-western states through a consignment of African rodents (origin Ghana) destined for the pet trade (34). Local surveillance at the site of animal carcass disposal did not detect evidence of the virus in feral/wild rodent populations.

Three genera of African rodent, Graphiurus, Cricetomys and Funisciurus (African dormice, giant pouched rat, rope squirrel, respectively) were implicated as vehicles of virus introduction during the initial importation event (32), (35).

Studies performed subsequently to assess the competence of each species to serve as natural reservoirs of the virus demonstrated that, in general, though none showed ‘tolerance’ (for example, virus amplification and shedding in the absence of evident disease), each was capable of being infected and of shedding viable virus for extended periods of time through varied routes (36 to 40).

Pox viruses, including MPXV, are very stable in the environment and therefore exposure of wild or pet rodents to contaminated household rubbish cannot be excluded. Wildlife involvement was ruled out in the cases in the USA in 2003, where wildlife surveillance was conducted, and surveillance around outbreaks in Nigeria have not found infected wild trapped rodents, but more research is needed in this area. An effective isolation period should therefore take into account the date from when the household has been decontaminated or the pet removed from the environment.

Will there be human exposure?

Outcome: no – general population; yes – for individuals interacting with infected pets (notably rodents) and their contaminated environments.

Quality of evidence: good.

MPXV enters the body through broken skin (even if the wound is not visible), respiratory tract, or the mucous membranes (eyes, nose, or mouth).

Human-to-human transmission is thought to occur either through large respiratory droplets (these respiratory droplets generally cannot travel more than a few feet, and so prolonged face-to-face contact is required), direct contact with body fluids or lesion material, and indirect contact with clothing or linens (such as bedding or towels) used by an infected person.

Animal-to-human transmission may occur when a person comes into close contact with the saliva, blood or other bodily fluids of an infected animal. If clinical signs, such as pustules and skin lesions are present, the process of desquamation can lead to environmental contamination.

Exposures may include being bitten or scratched by an infected animal, preparation of infected wild animal carcasses for consumption, or contact with a contaminated environment frequented by an infected animal (such as contaminated animal bedding, feeding bowls, water bottles).

Pet owners of fancy rats and other domestically kept rodents are usually in close contact with their pets, and their environments (for example housing, bedding, feeding materials). Based on transmission pathways of Hanta- (41) and Borna-viruses (42), there are known risk pathways for transmission, including cleaning cages.

The MPXV is an ACDP Category 3 pathogen, meaning it can cause severe human disease and may be a serious hazard to those handling and processing samples (for example healthcare workers, laboratory staff) if appropriate personal protective equipment is not worn.

Are humans highly susceptible?

Outcome: yes.

Quality of evidence: good.

MPX is an ACDP Category 3 pathogen which can cause severe disease. It is usually a self-limiting disease with the symptoms lasting from 2 to 4 weeks. Severe cases occur more commonly among children and are related to the extent of virus exposure, patient health status and nature of complications. Underlying immune deficiencies may lead to worse outcomes.

Smallpox vaccine, cidofovir, and tecovirimat can be used to control outbreaks of MPX (43). Vaccination against smallpox can be used for both pre- and post-exposure and is up to 85% effective in preventing MPX disease (13).

People vaccinated against smallpox in childhood may experience a milder disease. People younger than 40 to 50 years of age (depending on the country) may be more susceptible to MPX due to cessation of smallpox vaccination campaigns globally after eradication of the disease.

The extent to which asymptomatic infection may occur is unknown.

Is this disease highly infectious in humans?

Outcome: yes/no.

Quality of evidence: satisfactory.

Historically, cases of MPX in humans have been considered rare and zoonotic. In recent years, there has been increased reports of cases from endemic countries. Most outbreaks in the past have been short-lived and self-limiting, with only limited human-to-human transmission.

People vaccinated against smallpox in childhood may experience a milder disease. Immunity in those who were vaccinated against smallpox would confer cross protection, but this population is declining in most countries.

Generally, pox viruses do not have high reproductive rates and thus may not be considered highly infectious, however the reproductive rate for the outbreaks in Europe is not known and therefore we cannot apply this to a human-to-animal infection. Close and/or prolonged contact with an infected human or animal is required for transmission to take place.

Infectiousness may be considered higher for individuals partaking in activities which would result in close skin contact or exposure to infectious air droplets and/or bodily fluids or material from desquamation (43).

Outcome of probability assessment

The probability of human infection with MPXV in the general UK population is considered very low.

For individuals interacting with infected pets (notably rodents) and their contaminated environments, the probability would be considered moderate to high.

Step 2: Assessment of the impact on human health

The scale of harm caused by the infectious threat in terms of morbidity and mortality: this depends on spread, severity, availability of interventions and context.

Please read in conjunction with the impact algorithm found at Annex B.

Is there human-to-human spread of this pathogen?

Outcome: yes.

Quality of evidence: good.

Human-to-human transmission of MPX may occur through contact with clothing or linens (such as bedding or towels) used by an infected person, direct contact with MPX skin lesions or scabs and/or through coughing or sneezing of an individual with a MPX rash.

Human-to-human transmission can also occur through large respiratory droplets, which generally cannot travel more than a few feet, and so prolonged face-to-face contact with an infected person is required. Individuals that may have direct skin contact with an infected individual may have a greater exposure risk to MPX infection.

Is the UK human population susceptible?

Outcome: yes.

Quality of evidence: good.

See above evidence.

Does it cause severe disease in humans?

Outcome: yes/no.

Quality of evidence: satisfactory.

MPX is usually a self-limited disease with symptoms lasting from 2 to 4 weeks. The illness is often mild and most of those infected will recover without treatment. Disease usually begins with fever, myalgia, fatigue and a headache (44).

Within 1 to 5 days after the appearance of fever, a rash develops, often beginning on the face then spreading to other parts of the body. The rash progresses through different stages before finally forming a scab which later falls off.

The onset of rash is typically considered the start of the infectious period (45), and an individual is contagious until all the scabs have fallen off and there is intact skin underneath. The scabs may also contain infectious virus material.

Severe cases occur more commonly among children (13) and are related to the extent of virus exposure, patient health status and the nature of complications. In endemic countries, complications include secondary infections, bronchopneumonia, sepsis, encephalitis, and infection of the cornea impeding vision (46).

Underlying immune deficiencies may also lead to worse outcomes. Disease severity is also dependent on the MPXV clade an individual is infected with.

Historically, the less common Congo Basin clade has caused more severe disease (CFR up to 10%) and may be more transmissible compared to the West African clade (CFR approximately 1%) (47, 48).

Is it highly infectious to humans?

Outcome: yes/no.

Quality of evidence: satisfactory.

See above evidence.

Are effective interventions (preventative or therapeutic) available?

Outcome: yes.

Quality of evidence: good.

There are no vaccines or treatments that have been developed specifically for MPX. Clinical care for MPX is mainly supportive. Patients should be offered fluids and food to maintain adequate nutritional status and secondary bacterial infections should be prevented and treated (13).

An antiviral agent known as tecovirimat, that was developed for smallpox, was licensed by the European Medical Association (EMA) for MPX in 2022 based on data in animal and human studies. Smallpox vaccine, cidofovir, and tecovirimat can be used to control outbreaks of MPX (43).

Vaccination against smallpox can be used for both pre- and post-exposure, and is up to 85% effective in preventing MPX disease (13).

Appropriate respiratory isolation of suspected and confirmed MPX cases is essential for preventing transmission by respiratory and contact routes. Scabs are also infectious and care must be taken to avoid infection through handling contaminated clothing or linen (such as bedding or towels) that has been used by an infected person.

Individuals cleaning or decontaminating rooms that a patient with MPX has spent significant time in should wear appropriate personal protective equipment to avoid direct contact with contaminated material during the decontamination process (20).

Isolation of pets to prevent further contacts with uninfected people should be applied to non-rodent pet animals as a precaution, and provided the welfare of the animal is not compromised. However, where there are rodent pets present, the evidence base is stronger that they can contribute to MPXV spread amongst rodents and to people in direct contact (43).

The rodent pets that were exposed to the virus in a contaminated household should not be handled directly and should be prevented from contact with any wild or peridomestic rodents.

Would a significant number of people be affected?

Outcome: no.

Quality of evidence: good.

Within the UK, well established and robust public health interventions are implemented in response to cases of MPX infection. This involves the isolation and treatment (if required) of suspected and confirmed MPX cases, and extensive contact tracing designed at preventing further transmission.

Ring vaccination, using the modified vaccinia Ankara (MVA-BN) (Imvanex) Smallpox vaccine, has also been used in the UK in response to previous MPX incidents (49).

There is no requirement for pet rodents to be registered in the UK. Predicted numbers of pet rodents in the UK is based mainly on sales data for pet food and is estimated at around 2 million households (as opposed to 12 million each for cats and dogs) (50). There is no data for imports of ‘exotic pets’.

As most rodents are kept in cages within the household, and may be handled frequently, the level of exposure to owners is likely to be high, but less so for visitors or household members who are not comfortable with handling small mammals. Therefore, the level of exposure at the population level is considered low.

Contact with peridomestic rodents (house mice predominantly) cannot be excluded for any household with pet rodents. Therefore, there would be a potential exposure route for peridomestic rodents, but these animals are even less likely to have close direct contact with a human.

Outcome of impact assessment

The impact of MPX on human health in the UK is considered very low to low.

Annex A. Assessment of the probability of infection in the UK population algorithm

Accessible text version of Annex A

Outcomes are specified by a ☑ (tick) beside the appropriate answer.

Question 1: Is this a recognised human disease?

Yes: go to question 3 ☑

No: go to question 4

Question 2: Is this a zoonosis or is there zoonotic potential

Yes: go to question 3

No: probability of infection in UK population is very low

Question 3: Is this disease endemic in the UK?

Yes: go to question 7

No: go to question 4 ☑

Question 4: Are there routes of introduction into the UK?

Yes: go to question 5 ☑

No: probability of infection in UK population is very low

Question 5: Are effective control measures in place to mitigate against these?

Yes: probability of infection in UK population is very low

No: go to question 6 ☑

Question 6: Do environmental conditions in the UK support the natural reservoirs/vectors of disease?

Yes: go to question 7 ☑

No: probability of infection in UK population is very low

Question 7: Will there be human exposure

Yes: Individuals interacting with infected pets (notably rodents): Go to question 8 ☑

No: probability of infection in general UK population is very low ☑

Question 8: Are humans highly susceptible?

Yes: go to question 9 ☑

No: probability of infection in UK population is low

Question 9: Is this disease highly infectious in humans?

Yes: probability of infection in individuals interacting with infected pets (notably rodents) is high. ☑

No: probability of infection in individuals interacting with infected pets (notably rodents) is moderate. ☑

Annex B. Assessment of the impact on human health algorithm

*This question has been added to differentiate between those infections causing severe disease in a handful of people and those causing severe disease in larger numbers of people. ‘Significant’ is not quantified in the algorithm but has been left open for discussion and definition within the context of the risk being assessed.

Accessible text version of Annex B

Outcomes are specified by a ☑ (tick) beside the appropriate answer.

Question 1: Is there human-to-human spread?

Yes: go to question 4 ☑

No: go to question 2

Question 2: Is there zoonotic or vector borne spread?

Yes: go to question 3

No: impact on human health in the UK is very low

Question 3: Is the animal host or vector present in the UK?

Yes (animal host): go to question 4

No (vector): impact on human health in the UK is very low

Question 4: Is the population susceptible?

Yes: go to question 5 ☑

No: impact on human health in the UK is very low

Question 5: Does it cause severe human disease?

Yes (immunocompromised individuals): go to question 8 ☑

No: go to question 6 ☑

Question 6: Is it highly infectious to humans?

Yes: go to question 9 ☑

No: go to question 7 ☑

Question 7: Are effective interventions available?

Yes: impact on human health in the UK is very low ☑

No: impact on human health in the UK is low

Question 8: Would a significant number of people be affected?

Yes: go to question 10

No: go to question 9 ☑

Question 9: Are effective interventions available?

Yes: impact on human health in the UK is low ☑

No: impact on human health in the UK is moderate

Question 10: is it highly infectious to humans?

Yes: go to question 12

No: go to question 11

Question 11: Are effective interventions available?

Yes: impact on human health in the UK is moderate

No: impact on human health in the UK is high

Question 12: Are effective interventions available?

Yes: impact on human health in the UK is high

No: impact on human health in the UK is very high

References

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